Bed sores and pressure ulcers in nursing homes
Shalhoub Law Injury & Accident represents nursing home residents with pressure ulcers, and their families in West Palm Beach and throughout Palm Beach County. That includes whether the ulcer was avoidable, and the 75-day presuit period before a case can be filed. Attorney Paul R. Shalhoub spent years defending insurance companies before he began representing injured people, and he handles every case himself, from the first call through trial.
A pressure ulcer is not a normal part of getting old or being sick in a nursing home. Federal regulation starts from the opposite assumption: a resident “does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable.”
That sentence, from 42 C.F.R. 483.25(b)(1)(i), is where these cases begin and usually where they end. The facility’s defense is that the ulcer was unavoidable. Whether that is true is answered almost entirely by the chart: whether the resident was assessed for risk on admission, whether a care plan answered that risk, and whether anyone documented that the plan was actually carried out.
The full regulation requires that a resident “receives care, consistent with professional standards of practice, to prevent pressure ulcers,” and that a resident who has one “receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.” Two duties, and families usually learn about the second one only when the first has already failed.
What this claim involves
Who can be held responsible
Under section 400.023(1), the licensee, its management or consulting company, its managing employees and direct caregivers. A passive investor is not liable, and anyone else only by leave of court.
What has to be proven
Duty, breach, legal cause and damage, each by a preponderance of the evidence. Section 400.023(4) is explicit that this part “does not create strict liability.”
How long you have
Two years from the incident or from discovery with due diligence, and never more than four years from the incident, under section 400.0236(1).
What it costs to hire Paul Shalhoub
Nothing up front. The consultation is free and the fee is contingent.
Avoidable or unavoidable is the whole case
Two words, and a documentary record that either supports them or does not.
A facility defending a pressure ulcer claim will say the resident was frail, immobile, malnourished, diabetic, incontinent, on vasopressors, at the end of life — all of which can be true, and none of which is an answer by itself. The regulation contemplates that some ulcers are unavoidable. It conditions that on the individual’s clinical condition demonstrating it.
Demonstrating it means a record. For a sore to be credibly unavoidable, the chart generally has to show that the facility identified the risk, planned for it, carried out the plan, reassessed when the resident’s condition changed, and did all of that while the ulcer still developed. A chart that shows a risk score on admission and nothing afterward is not a record of an unavoidable injury. It is a record of an unmanaged one.
This is why these cases are won or lost in the medical records rather than in argument, and why the first substantive step is getting the complete file — not the discharge summary, not a narrative, the whole chart.
What a pressure ulcer is, and where it forms
Plain description, because families are usually told a word and not what it means.
A pressure ulcer is tissue death caused by sustained pressure cutting off blood supply, usually where bone is close to the skin. It forms over the tailbone and sacrum, the heels, the hips, the sitting bones, the ankles, the shoulder blades and the back of the head. Pressure from a chair causes them as reliably as pressure from a bed, which is why the old term bed sore understates the problem.
Clinicians stage them by the depth of tissue involved, from intact skin that does not blanch when pressed, through partial and full thickness skin loss, to a wound exposing muscle, tendon or bone. Two further categories matter in a claim: an ulcer whose depth cannot be determined because the base is covered, and a deep tissue injury that looks like a bruise and is already worse underneath than it appears.
The clinical point families are rarely told: a sore that looks small on the surface can be undermined and tunneled far beyond its visible edge. A wound measured only by its opening is measured wrong, and the measurement is in the chart.
Where an ulcer reaches bone it can seed infection into the bone, and from there into the bloodstream. Osteomyelitis and sepsis are how a pressure sore kills someone, and when a resident dies after one, the claim becomes a different claim. Wrongful death claims in Florida →
What Florida law adds to the federal standard
The resident’s rights, and the exact weight a regulatory violation carries.
Section 400.022(1)(l) gives a nursing home resident “the right to receive adequate and appropriate health care and protective and support services … consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency.”
Then section 400.023(4) does something unusual and worth quoting precisely. The claimant must prove duty, breach, legal cause and damage by a preponderance of the evidence; this part “does not create strict liability”; and a violation of the rights in section 400.022, of any standard in this part, or of “any applicable administrative standard or guidelines of this state or a federal regulatory agency is evidence of negligence but is not considered negligence per se.”
That is the honest shape of the law. A federal deficiency citation or a state survey finding does not win the case by itself. It is admissible evidence of negligence, which has to be put together with the chart, the standard of care and the expert testimony. Section 400.023(5) sets the facility’s duty as reasonable care — “that degree of care which a reasonably careful licensee … would use under like circumstances” — and (6) holds a licensed nurse to “the prevailing professional standard of care for a nurse.”
The 75 days before anything can be filed
Why a nursing home case takes longer to start than a car accident case, and why waiting is expensive.
Section 400.0233(2) requires that before a claim for a resident’s rights violation or negligence is filed, the claimant notify each prospective defendant by certified mail, return receipt requested, identifying the rights violated and the negligence alleged, with a brief description of the injuries. The notice must carry “a certificate of counsel that counsel’s reasonable investigation gave rise to a good faith belief that grounds exist for an action against each prospective defendant.”
Then subsection (3)(a): “No suit may be filed for a period of 75 days after notice is mailed to any prospective defendant.” During those 75 days the facility and its insurer evaluate the claim through a procedure the statute describes, and they are required to evaluate it in good faith.
Practically, that means a lawyer cannot send a notice the week after a family calls. The certificate of counsel requires an investigation first, and the investigation requires the records. So the real sequence is: obtain the complete chart, have it reviewed, serve the notice, wait 75 days, and only then file. Against a two-year deadline that runs from the incident or its discovery, a family that waits eighteen months has left less room than they think.
What Paul Shalhoub does on a pressure ulcer claim
Concretely, in the order it happens.
| Request the complete chart, not a summary | Admission assessments, every risk assessment and its scores, the care plans and every revision, nursing notes, treatment administration records, wound measurements and photographs, physician and wound consult notes, weights and nutrition records, laboratory values, and the resident assessment instrument submissions. The gaps are as informative as the entries |
| Reconstruct the timeline against the admission | Whether the ulcer was present on admission or developed in the facility is the first factual question, and it is answered by the skin assessment done at admission — or by its absence. An ulcer first documented at stage three was not first present at stage three |
| Compare the care plan to the care documented | Repositioning, pressure-redistributing surfaces, heel offloading, incontinence care, nutrition and hydration support. The question is never whether the plan said the right thing. It is whether the record shows it happened, shift after shift |
| Pull the staffing records for the shifts in question | Who was assigned, how many residents each aide carried, and how often agency staff covered. Pressure ulcers are a staffing injury more often than a clinical mystery |
| Get the facility’s survey history | State and federal survey findings and deficiency citations for the same facility, including prior findings about skin integrity. Under section 400.023(4) they are evidence of negligence, not negligence per se, so they are used as part of a case rather than as the case |
| Identify the right defendants early | Section 400.023(1) limits the claim to the licensee, its management or consulting company, its managing employees and direct caregivers. Reaching anyone else requires leave of court on a reasonable showing under 400.023(3), and the ownership structures are usually layered |
| Find the admission agreement | Because of what is often in it: an arbitration provision, a responsible-party signature, and terms about who agreed to what on whose behalf. Whether it binds the resident or the family member who signed is a question with a real answer, and it is answered from the document |
Do you need a lawyer for a bed sore?
An honest answer, including when it is no.
Where you probably do not. Redness over a heel or the tailbone that you raised with the nurse, that the facility responded to with a pressure-relieving mattress and a repositioning schedule, and that resolved within days without an open wound. That is a facility doing its job after a near miss, and there is no claim in it.
Where you probably do. The ulcer reached full thickness, exposed muscle or bone, or required surgical debridement or a flap. There was an infection, osteomyelitis or sepsis. It developed after admission and was not documented until it was already advanced. The facility cannot explain why the risk assessment was never updated. The resident was hospitalized because of it. The resident died. Or the facility is asking you to sign something — a release, an arbitration agreement, a transfer form — while this is unresolved.
The consultation is free, so finding out which one you are in costs a phone call.
An illustration, not a prediction
A composite of how these files actually move. Every case is different and nothing here predicts a result.
An eighty-one-year-old man is admitted for rehabilitation after a hip fracture. The admission skin assessment records intact skin. He scores at high risk on the facility’s risk assessment, and the care plan calls for repositioning, a pressure-redistributing mattress and heel protection.
Five weeks later his daughter notices a dressing on his sacrum that nobody mentioned. The wound is already full thickness. The chart has a risk score from admission and no reassessment after it, repositioning entries that stop appearing for long stretches, a weight loss of eleven pounds with no dietary note, and the first wound measurement dated the week the daughter asked. He is hospitalized with an infection a month after that.
The facility’s position is that the ulcer was unavoidable given his immobility and nutrition. What answered it was not an expert opinion about immobility. It was the admission assessment showing intact skin, the absence of any reassessment, the gaps in the repositioning record, and the weight loss nobody charted — the facility’s own chart, in the order the chart created.
What to gather
If this is happening now, the photographs matter more than anything else on the list.
| Photographs, dated, each time the wound is visible | With something for scale if possible. Wounds change weekly and a photographic series is the only independent record a family can create |
| Your own written notes of each visit | What you saw, what you were told, who told you, and when. Contemporaneous notes carry weight that recollection does not |
| The complete medical records, requested in writing | From the facility and from every hospital involved. Request the entire chart rather than a summary |
| The admission agreement and every form signed | Including anything a family member signed as a responsible party, and any arbitration provision |
| Names of staff and of other families | Aides, nurses and the wound care nurse, and anyone who told you something that is not in the chart |
| Hospital records showing what the sore caused | Debridement, antibiotics, a bone scan, a blood culture, an intensive care admission |
| Anything about weight and food intake | Nutrition is central to both the injury and the defense, and weight records are often the clearest evidence of neglect in the file |
Common questions
Are bed sores always a sign of neglect?
Not always, and the federal regulation says so: a resident does not develop pressure ulcers “unless the individual’s clinical condition demonstrates that they were unavoidable.” The question in every case is whether the chart demonstrates that, which requires a risk assessment, a care plan answering it, documentation that the plan was carried out, and reassessment as the resident changed.
The facility says it was unavoidable because of my mother’s condition.
That is the defense, and it is a conclusion rather than a fact. Frailty, immobility, diabetes and poor nutrition are risk factors that trigger the duty to prevent, not excuses for failing to. The record either shows the facility managed the risk or it does not.
What if the sore was already there when she was admitted?
Then the duty is the second one in 42 C.F.R. 483.25(b)(1)(ii): necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. A sore present on admission that deteriorated two stages in the facility is a claim about treatment rather than prevention.
Who can be sued?
Under section 400.023(1), the licensee, the licensee’s management or consulting company, its managing employees and any direct caregivers. A passive investor is not liable, and reaching any other individual or entity requires leave of court on a reasonable showing under section 400.023(3).
Does a state inspection finding mean we win?
No. Section 400.023(4) makes a violation of residents’ rights or of a state or federal regulatory standard “evidence of negligence but … not considered negligence per se.” It is useful evidence that still has to be connected to the standard of care and to what happened to this resident.
How long do we have to bring a claim?
Two years from the incident, or two years from when it was discovered or should have been discovered with due diligence, and in no event more than four years from the incident, under section 400.0236(1). Where fraudulent concealment or intentional misrepresentation prevented discovery, subsection (2) extends it to two years from discovery with an outer limit of six years.
Why can we not file right away?
Section 400.0233 requires presuit notice by certified mail to each prospective defendant, with a certificate of counsel based on a reasonable investigation, and then no suit may be filed for 75 days. The investigation has to come first, which is why the records request is the first step rather than the lawsuit.
She signed an arbitration agreement when she moved in. Is the case over?
Not necessarily. Whether an arbitration provision in a nursing home admission packet is enforceable, and against whom, depends on the document, on who signed it and in what capacity, and on its terms. It is read before anyone assumes it decides anything.
What if my father died after the pressure sore?
Section 400.023(1)(b) addresses it directly: where the claim alleges rights violations or negligence that caused the resident’s death, the claimant elects survival damages under s. 46.021 or wrongful death damages under s. 768.21 after the verdict and before judgment is entered. Who can recover under the Florida Wrongful Death Act →
It happened in an assisted living facility, not a nursing home. Same law?
A parallel one. Chapter 400, Part II governs nursing homes. An assisted living facility is governed by Chapter 429, and section 429.29(1) gives a resident whose rights under that part are violated a cause of action, with its own structure for damages. Which license the facility holds is confirmed before anything is sent.
Talk to Paul, not a case manager
If a sore is open right now, photograph it and call. Paul R. Shalhoub will tell you what records to request and what the chart is likely to show. Consultations are free and confidential. We advance case costs, and you owe no attorney’s fees or reimbursement of those costs unless we recover compensation for you.
Call (561) 208-5058 Free case review
Shalhoub Law Injury & Accident, 1011 N Olive Ave, West Palm Beach, FL 33401. This describes Florida and federal law as of 26 October 2026 and applies to claims in Florida. It is general information, not legal advice, and reading it does not create an attorney-client relationship. Past results do not guarantee or predict a similar outcome.